Good Hope Eye Clinic

Allergic Conjunctivitis

David Kinshuck


 

Introduction: allergic ocular surface disease

There are several types of allergic eye disease:

Causes

the symptoms

Examination

Allergic conjunctivitis, including children:

Allergic conjunctivitis is a common condition. The eyes become red and very itchy, and generally the sight is good. There may be a runny nose and sufferers may feel unwell. The allergy usually gets better itself, but the condition then returns every now and again. 'Itchy red eyes' occurring now and again, particularly if you suffer from hey fever or other allergies, is the main symptom.

Many people with allergic eye disease also have dry eyes and blepharitis, which may also be helped with treatment. 'Dry eyes' feel as though they are burning; eyes with blepharitis feel irritable and gritty.

If the allergy occurs during the hay fever season, then it is related to hay fever, and termed 'seasonal allergic conjunctivitis'. But if it occurs all the year round you are probably allergic to dust, and termed 'perennial'.
Alternatively you may be allergic to cat fur, for instance. 

Pollution in the air increases allergy rates considerably. Some people are allergic to contact lens solutions. 

 

Medical treatment

This page outlines different treatments. Here is a step-wise treatment plan. If the condition is severe, advice from an ophthalmologist is essential.
Anyone with sore eyes should ideally not use more than 4 eye drops containing preservative a day in an eye. People with dry eyes need preservative free drops.

Patients become sensitive to wind and eye drops which may then lead to poor compliance.

Optichrom and related drops

Optichrom eye drops are virtually 100% safe for long term use and can be very helpful. They stop the 'allergy cells' on the surface of your eye, the mast cells, releasing chemicals that make your eyes irritable. This is the first drop to try, but if is it is not effective try the others below. As they work differently you may use them in addition to Optichrom.
Nedocromil  (Rapitil) and Lodoxamide are more modern and quicker acting forms of Optichrom and should tried if Optichrom has not helped enough.

 

Preservative free lubricants

These are very helpful. There are many: e.g. Vismed, hylofort, Hyabak, Clinitas preservative free. VitApos at night seems to be the most effective night time lubricant, Xailin night second best.

 

Opatanol (olopatadine)

Opatanol, Olopatadine bd (twice/day) US name is Patanol It is a mast cell stabiliser/antihistamine, and can be very effective see and see.

 

Antihistamine tablets

Antihistamine tablets such as Cetirizine can be very helpful, but there are many others. Levocetirizine (5mg >6y age), Loratidine Others.
Try them if your allergy is bad. They may make you too tired but are generally safe, and they help your runny nose and the fever part of hay fever.
With hay fever it is best to start the treatment early before the condition gets hold, as this way it is easier to control.
There are many types of antihistamine tablets and some make more people tired than others. Ask your doctor and pharmacist for advice.

 

Steroid drops

If Nedocromil or Opatanol, do not work, steroid drops may work, used in addition. Try to avoiding the triggers to your allergy as below, especially if you have a dust allergy.
In practice very few people need steroid drops if they avoid dust (as below) or use the drops and antihistamine tablets above. Generally steroid drops are best avoided.
If you do have to use them, the main steroid drop is prednisolone minims, and this should not be used without an ophthalmologist's advice, unless your GP is experienced in its use and you only use it for short periods.

There are many ways to use the prednisolone drops. The 'minims' type have no preservative and are generally best for allergy patients.
If your eyes are red and itchy, you may need to use them quite often, perhaps 4 times a day. As soon as the redness fades, usually about 4 days, start to reduce the dose of the steroid to 3 and them 2 times a day.
Once the redness has faded, continue for a few days and then try to stop them.

If the redness and itch returns every time you stop, and as advised by your ophthalmologist, you may need to use a low dose regularly, such as once a day. This is reasonably safe during the hay fever season for short periods.

Steroid drops have many side effects if used in the wrong manner. You need to be certain that you do have 'allergic conjunctivitis' and not another condition, and most people can recognise when their eyes are red and itchy the condition has returned.
But if you have a scratchy and painful eye, you may have an ulcer and the drops should be stopped and you should get expert advice.
Similarly, if you need a lot of steroid drops for many months you may develop glaucoma, so you will need regular checks and expert advice. Long term use will lead to cataracts also. Even short term use of steroid drops can activate herpes simplex keratitis.
Very weak steroid drops, such as prednisolone 0.1 - 0.05% are available from Moorfields eye hospital and some others, and these may be safer and helpful.

 

Treat the nose

Rhinolast and nasal spray, need to treat nose, and this helps eyes.

 

Immunotherapy for hay fever
(& seasonal allergic conjunctivitis)

In many parts of the country immunotherapy is available for hay fever sufferers, but is difficult to access in Birmingham. Some people dispute the effectiveness of immunotherapy, but it is probably very helpful for some people, and slightly less helpful for others.
Your GP will need to advise you about immunotherapy in your specific case, but if your hay fever is bad the medical literature advises it should be available to you and recommends you consult an immunologist.
Homeopathic remedies help some people, but not others, and are not suitable as a replacement for immunotherapeutic advice if your symptoms are severe and you need steroid tablets.
See  www.asthma.org.uk, especially if you have asthma.

 

General measures

Dust allergy (& perennial allergic conjunctivitis): precautions

If you have a dust allergy there is plenty you can do. Visit the websites below for more details. This page has many details....although written for asthma patients, advice may be helpful.

Lifestyle issues and Mediterranean diet

Lifestyle issues are critically important

Summarising: stepwise treatment of allergic conjunctivitis, including children

Stepwise treatment of allergic conjunctivitis
  • Look again at prevention, especially if you are allergic to dust.
  • Anti-dust measures such as freezing bedding/pillows/pillow cases for a few hours or buying a new pillow or special covers can help.
  • Healthy diet, vegetables, fish, exercise, no smoking, vitamin D, avoiding obesity
  • Nedocromil and Lodoxamide Optichrom (or Rapitil) drops (completely safe).
  • Lubricants such as Vismed, hylofort, Hyabak, Clinitas preservative free. VitApos at night, Xailin night second best.
  • certainly seek your GPs help. 
  • Olopatadine (Opatanol) bd (twice/day) helps many people.
  • At this stage it is best to seek specialist help if you are still having severe problems,
  • Antihistamine tablets help. You may need a slightly higher than recommended dose if your hey fever is very troublesome. Cetirizine but there are many others. Levocetirizine (5mg >6y age), Loratidine Others.
  • prednisolone minims, and this should not be used without an ophthalmologist's advice, unless your GP is experienced in its use and you only use it for short periods, start 4 times a day for a week and reduce.
  • Severe cases, guided by an ophthalmologist. Protopic: Occ tacrolimus  0.03 % bd to skin around eye, allowing a little to enter the eye.

 

 

Specific types

 

Atopic keratoconjunctivitis (AKC)

Here the lid is affected, and patients may have severe systemic disease, asthma or eczema of the face. The condition fluctuates.

The lids need intensive treatment. Without meibomian gland secretions, tears do not spread, and so a dry eye effect results, leading to corneal disease and ulcers.

 

Stepwise treatment of chronic atopic conjunctivitis
  • Look again at prevention, especially if you are allergic to dust.
  • Anti-dust measures such as freezing bedding/pillows/pillow cases for a few hours or buying a new pillow or special covers can help.
  • Healthy diet, vegetables, fish, exercise, no smoking, vitamin D, avoiding obesity
  • Nedocromil and Lodoxamide Optichrom (or Rapitil) drops (completely safe).
  • certainly seek your GPs help. 
  • Olopatadine (Opatanol) bd (twice/day)
  • Lubricants such as Vismed, hylofort, Hyabak, Clinitas preservative free. VitApos at night, Xailin night second best.
  • At this stage it is best to seek specialist help if you are still having severe problems,
  • Antihistamine tablets help. You may need a slightly higher than recommended dose if your hey fever is very troublesome. Cetirizine but there are many others. Levocetirizine (5mg >6y age), Loratidine Others.
  • prednisolone minims, and this should not be used without an ophthalmologist's advice, unless your GP is experienced in its use and you only use it for short periods, start 4 times a day for a week and reduce.
  • treat lids doxycycline 50mg once daily
  • lid hygiene
  • beware of herpes simplex keratitis when on steroids (also glaucoma, cataracts, corneal melting), but nevertheless steroid drops are often needed.
  • short courses or a low dose longer term of stronger steroids such as dexamethasone 4 times a day for a short period, reducing to a much lower maintenance dose.
  • Protopic: Occ tacrolimus  0.03 % twice daily to skin around eye, allowing a little to enter the eye. Tacrolimus is more effective than Cyclosporine.
  • if still very troublesome, expert advice
  • Systemic drugs if very severe indeed.
    • Montelukast..variable effects
    • Omalizmumab...injection,¬† helpful.
    • Systemic steroids prednisolone
      1mg/ kg for 3 days then stop
    • systemic Tacrolimus, azathioprine or Cellcept
    • probiotics may help JAMA 16  what are they

 

 

Vernal keratoconjunctivitis (VKC), previously called GPC (giant papillary conjunctivitis) , vernal catarrh, shield ulcers

Vernal keratoconjunctivitis (VKC), previously called GPC (giant papillary conjunctivitis) ,

enlarge
lumps develop under the top eyelid

I am not expert in treating these conditions, but

Stepwise treatment of vernal keratoconjunctivitis
  • Look again at prevention, especially if you are allergic to dust.
  • Anti-dust measures such as freezing bedding/pillows/pillow cases for a few hours or buying a new pillow or special covers can help.
  • Healthy diet, vegetables, fish, excercise, no smoking, vitamin D, avoiding obesity
  • ophthalmologists help
  • Olopatadine (Opatanol) bd (twice/day)
  • Lubricants such as Vismed, hylofort, Hyabak, Clinitas preservative free. VitApos at night, Xailin night second best.
  • steroid drops: dexamethasone drops 4 times a day for a short period, reducing to a much lower maintenance dose.
  • AND
  • Protopic: Occ tacrolimus  0.03 % twice daily to skin around eye, allowing a little to enter the eye. Tacrolimus is more effective than Cyclosporine.
  • beware of herpes simplex keratitis when on steroids (also glaucoma, cataracts, corneal melting), but nevertheless steroid drops are often needed.
  • steroid injections in the upper lid

 

Shield ulcers

shield ulcer...shown by he green circleenlarge

shield ulcers on the cornea (shown in green)

 

 

 

 

 

Limbitis, a type of Vernal keratoconjunctivitis (VKC)

 

limbitis

enlarge

Treat as VKC above.

 

 

 

 

 

 

Recurrent angioedema

Allergic rhinitis in children: treatment

 

Eczema of eyelids

 

Links